Call for improved military policy to support breastfeeding among U.S. armed forces

Abstract

Human milk saves lives, reduces health care costs, and improves the health of both mother and infant. For a small investment to support breastfeeding among active-duty women, the payoff for the U.S. military would be significant: retention of loyal and well-trained service personnel, improved health of women, and a reduction in Tricare costs. Providing breastfeeding support can help the U.S. armed forces retain valued servicewomen after childbirth. A model policy to support breastfeeding women would include on-site lactation support services and peer support, suitable areas available for milk expression and storage, reasonable break time, and a leave policy that incentivizes breastfeeding. Military families may face unique challenges when breastfeeding because of the need for combat readiness, deployment separations, fear about potential exposure to hazardous materials, and duty requirements. However, with optimal support and resources, women in the military can successfully provide breast milk for their infants throughout the first year of life (Martin et al., 2015Martin S. Drake E. Yoder L. Gibson M. Litke C. Active duty women's perceptions of breastfeeding support in the military setting.Military Medicine. 2015; 180: 1154-1160Crossref PubMed Scopus (8) Google Scholar). In the United States, overall breastfeeding initiation rates have improved to 81% (Centers for Disease Control and Prevention (CDC), 2016Centers for Disease Control and Prevention (CDC)Breastfeeding Report Card.2016http://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdfGoogle Scholar). However, disparities and inequities exist; minorities, younger age, less maternal education, and lower incomes levels are all characteristics associated with lower breastfeeding rates (U.S. Department of Health and Human Services, Office of the Surgeon General, 2011U.S. Department of Health and Human Services, Office of the Surgeon GeneralThe Surgeon General's call to action to support breastfeeding. Author, 2011http://www.surgeongeneral.govGoogle Scholar). Although initiation rates have improved, this is overshadowed by a persistent and rapid decline in breastfeeding rates measured at 6 and 12 months. The World Health Organization (WHO) and the American Academy of Pediatrics (AAP) recommend exclusive breastfeeding for at least 6 months and continued breastfeeding for at least a year (American Academy of Pediatrics, 2012American Academy of PediatricsPolicy statement: Breastfeeding and the use of human milk.Pediatrics. 2012; 129: e827-e841Crossref PubMed Scopus (3471) Google Scholar, World Health Organization, 2003World Health OrganizationGlobal strategy for infant and young child feeding. World Health Organization, Geneva, Switzerland2003Google Scholar). Currently, only 22% of infants are still receiving breast milk exclusively at 6 months, and we are far from meeting national health goals (Centers for Disease Control and Prevention (CDC), 2016Centers for Disease Control and Prevention (CDC)Breastfeeding Report Card.2016http://www.cdc.gov/breastfeeding/pdf/2016breastfeedingreportcard.pdfGoogle Scholar). We know that women frequently wean the infant as they are going back to work. It has been estimated that if women in the United States breastfeed according to the recommended levels, the total cost savings to the United States would be $3.6 billion annually (Bartick and Reinhold, 2010Bartick M. Reinhold A. The burden of suboptimal breastfeeding in the United States: A pediatric cost analysis.Pediatrics. 2010; 125: e1048-e1056Crossref PubMed Scopus (465) Google Scholar). For organizations, the case for breastfeeding is clear, and the potential payoff is significant: more satisfied, loyal employees, and cost savings to the employer. These savings are seen in retention of experienced employees, reduction in sick time taken by both moms and dads for children's illnesses, and lower health care and insurance costs (U.S. Department of Health and Human Services, 2008U.S. Department of Health and Human Services, Health Resources and Services Administration (HRSA)The business case for breastfeeding: Employees' guide to breastfeeding and working. Author, 2008www.mchb.hrsa.gove/preganancyandbeyondGoogle Scholar). Thus, the cost of providing breastfeeding support is minimal, and the return on investment is high. Recently, progress has been made in support for military women who choose to breastfeed. The Army was the last branch of the armed forces to develop a policy regarding breastfeeding (2015–2016). These important policies and directives serve to protect breastfeeding women and to assure adequate facilities and work breaks for women who need to express milk for their babies. Policy analysis comparing the policies of other branches of the military (Air force, Navy, Marines, and Coast Guard) along with the U.S. Department of Labor/Fair Labor Standards Act requirements intended to protect all U.S. workers, suggests that some variation in these policies exists (Abdulwadud and Snow, 2012Abdulwadud O.A. Snow M.E. Interventions in the workplace to support breastfeeding for women in employment.The Cochrane Database of Systematic Reviews. 2012; 10: CD006177PubMed Google Scholar, Bai and Wunderlich, 2013Bai Y. Wunderlich S.M. Lactation accommodation in the workplace and duration of exclusive breastfeeding.Journal of Midwifery and Women's Health. 2013; 58: 690-696Crossref PubMed Scopus (36) Google Scholar, Froh and Spatz, 2013Froh E.B. Spatz D.L. A call to action: Ensuring reasonable break time for nursing mothers.Nursing Outlook. 2013; 61: 117-119Abstract Full Text Full Text PDF PubMed Scopus (3) Google Scholar, Murtagh and Moulton, 2011Murtagh L. Moulton A.D. Working mothers, breastfeeding, and the law.American Journal of Public Health. 2011; 101: 217-223Crossref PubMed Scopus (81) Google Scholar, Smith-Gagen et al., 2014Smith-Gagen J. Hollen R. Tashiro S. Cook D. Yang W. 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Breastfeeding in the military: Part II. Resource and policy considerations.Military Medicine. 2003; 168: 813-816Crossref PubMed Scopus (7) Google Scholar; Buckler, 2011Buckler A.G. The military health system and TRICARE: Breastfeeding promotion.Breastfeeding Medicine. 2011; 6: 295-297Crossref PubMed Scopus (5) Google Scholar, Haas et al., 2006Haas D.M. Howard C.S. Christopher M. Rowan K. Broga M.C. Corey T. Assessment of breastfeeding practices and reasons for success in a military community hospital.Journal of Human Lactation. 2006; 22: 439-445Crossref PubMed Scopus (22) Google Scholar, Martin et al., 2015Martin S. Drake E. Yoder L. Gibson M. Litke C. Active duty women's perceptions of breastfeeding support in the military setting.Military Medicine. 2015; 180: 1154-1160Crossref PubMed Scopus (8) Google Scholar, Rishel and Sweeney, 2005Rishel P. Sweeney P. Comparison of breastfeeding rates among women delivering infants in military treatment facilities with and without lactation consultants.Military Medicine. 2005; 170: 435-438Crossref PubMed Scopus (18) Google Scholar, Sleutel, 2012Sleutel M.R. Breastfeeding during military deployment: A soldier's story.Nursing for Women's Health. 2012; 16: 20-25Abstract Full Text Full Text PDF PubMed Scopus (5) Google Scholar, Stevens and Janke, 2003Stevens K.V. Janke J. Breastfeeding experiences of active duty military women.Military Medicine. 2003; 168: 380-384Crossref PubMed Scopus (23) Google Scholar, Uriell et al., 2009Uriell Z. Perry A. Kee A. Burress L. Breastfeeding in the navy: Estimates of rate, duration, and perceived support.Military Medicine. 2009; 174: 290-296Crossref PubMed Scopus (13) Google Scholar). Further research, as well as tracking of breastfeeding duration and exclusivity for infants of active-duty female personnel for comparison across branches, is recommended. More than 15% of the U.S. military comprises female service members. This issue has the potential to affect more than 200,000 women who are working in a male-dominated field. Without clear policy and policy enforcement, it is left up to the discretion of commanders and unit supervisors to provide lactation accommodations as they see fit for female military members under their supervision. Enlisted personnel, especially junior enlisted and minority women, are particularly vulnerable. Based on growing evidence concerning the health and financial benefits of breastfeeding for both mother and child, the Department of Defense (DoD) has taken steps to promote breastfeeding among active-duty mothers in the past decade. However, the lack of uniformity and specificity of some military lactation policies may lead to discrepancies and confusion. The Surgeon General's Call to Action to Support Breastfeeding (2011) and the American Academy of Family Physicians (AAFP) have encouraged the DoD to develop and implement lactation policies and statements in support of breastfeeding (AAFP, 2015American Academy of Family Physicians (AAF). Family physicians support breastfeeding (position paper). Retrieved from http://www.aafp.org/about/policies/all/breastfeeding-support.htmlGoogle Scholar, U.S. Department of Health and Human Services, Office of the Surgeon General, 2011U.S. Department of Health and Human Services, Office of the Surgeon GeneralThe Surgeon General's call to action to support breastfeeding. Author, 2011http://www.surgeongeneral.govGoogle Scholar). In addition, military family medical leave policies and flexible work schedules in line with the national family act could incentivize continued breastfeeding (AWHONN, 2015Association of Women's Health, Obstetric and Neonatal Nurses (AWHONN)Breastfeeding position statement.Journal of Obstetric, Gynecologic & Neonatal Nursing. 2015; 44: 145-150Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar). Six months of paid leave and flexible work/duty schedules during the next 6 months would be ideal. In the Coast Guard, male or female members have had the option of taking a one-time 2-year unpaid separation from active duty to care for a newborn with return to the same pay grade and benefits. The American Academy of Nursing recognizes the health benefits of breastfeeding for women, infants, and families and supports active-duty women who are breastfeeding in the military. These women comprise a select population of the workforce that commands particular attention with regard to breastfeeding support. The academy supports efforts to strengthen military policy to protect breastfeeding women at all ranks and in all branches of the uniformed services. •Tricare should enhance its coverage for breastfeeding mothers to include coverage for supplies, pumps, and lactation care provider services.•The U.S. DoD and Tricare should collaborate to track breastfeeding duration and exclusivity for infants of active-duty female personnel for comparison across branches and to promote consistency throughout the branches. The authors acknowledge the Expert Panel on Breastfeeding; Diane Spatz, PhD, RN-BC, FAAN, Expert Panel on Breastfeeding; the Military and Veterans Health Expert Panel; Mary Anne Dumas, PhD, RN, FNP-BC, GNP-BC, FAANP, FAAN, FNAP, Military and Veterans Health Expert Panel; Patricia Patrician, PhD, RN, FAAN, Military and Veterans Health Expert Panel; and the assigned Academy Board and Staff Liaisons: Deb Toney, Susan Albrecht, Cheryl Sullivan, and Kim Czubaruk.